A nurse is assessing a patient who becomes motionless and seems to stare at the wall and then experiences about 60 seconds of lip smacking and hand wringing. What should the nurse do?
a. Ask the patient about a history of absence seizures.
b. Contact the provider to report symptoms of a complex partial seizure.
c. Notify the provider that the patient has had a grand mal seizure.
d. Request an order for intravenous diazepam (Valium) to treat status epilepticus.
ANS: B
This patient showed signs of a complex partial seizure, characterized by impaired consciousness beginning with a period of motionlessness with a fixed gaze, followed by a period of automatism. The entire episode generally lasts 45 to 90 seconds. Absence seizures are characterized by loss of consciousness for a brief period (about 10 to 30 seconds) and may involve mild, symmetric motor activity or no motor signs. A grand mal seizure is characterized by jaw clenching and rigidity followed by alternating muscle relaxation and contraction and then periods of cyanosis, all with a loss of consciousness. Status epilepticus is a seizure that persists for 30 minutes or longer.
You might also like to view...
The home healthcare nurse is preparing an educational program for other healthcare providers regarding elder abuse. What information should the nurse include? Standard Text: Select all that apply
1. The typical abuser is the spouse. 2. The typical abuser is the adult child. 3. The typical elder who is abused is a woman. 4. The majority of abuse occurs in the home setting. 5. The majority of abuse occurs in the long-term care setting.
A clinic nurse is caring for a 40-year-old client who lives with his parents. The client's mother continues to do the client's laundry for him and gives him spending money. The nurse recognizes that this is an example of:
A) Taking over. B) Communicating indirectly. C) Belittling feelings. D) Making assumptions.
Which of the following aspects of rehabilitation is the responsibility of the nursing assistant?
A. Apply heat treatments and perform massage. B. Teach the patient how to do ADLs. C. Teach the patient to do strengthening exercises. D. Perform range-of-motion exercises with the patient.
When measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the patient's hand. How should the nurse document this finding?
A. Turner sign B. Trousseau sign C. Chvostek sign D. Cullen sign